Provider Demographics
NPI:1396756029
Name:LUBISICH, PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:LUBISICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SE 120TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4067
Mailing Address - Country:US
Mailing Address - Phone:360-256-1755
Mailing Address - Fax:360-882-8080
Practice Address - Street 1:300 SE 120TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4067
Practice Address - Country:US
Practice Address - Phone:360-256-1755
Practice Address - Fax:360-882-8080
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA44381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3798OtherWDS ID
WA409293OtherUNITED CONCORDIA/TRICARE